Allergic to Everything

For some reason, patients with numerous allergies to medications seem to be predominantly female. Are women really more likely to have allergic reactions to medications than men, or are they simply more likely to receive a greater variety of medications over time and thus discover that they are allergic to them? Or are women just more likely to complain about subtle adverse reactions than men? Is guano somehow involved?

I've seen plenty of elderly ladies with bewilderingly comprehensive allergy lists, but I always give them the benefit of the doubt. They have lived for all these decades despite their limitations, so they must be doing something right. Anyway, these matriarchs usually have one or two different antibiotic classes they are willing to accept, so I'm happy (relieved, honestly) to throw some Keflex and a prayer at their UTI and bid them farewell.

But what of the 20 year old who claims to be allergic to "every antibiotic known to man?" And who can actually recite many of these drugs from memory, despite the fact that she seems totally healthy and takes no medications? What if she someday develops pyelonephritis, pneumonia, or PID? I guess we'll cross that bridge when we get there. For the nonspecific febrile illness, all I can offer is Motrin and a pat on the back.

And a good luck wish to the next doc who sees her.

$54 million???

Only in America could a diaper-clad elderly nursing home resident's life be worth that much.

Grief Reaction

Chairs being thrown. Aunts and uncles collapsing, carted off on stretchers after fainting. A mother in tears, angrily and defiantly denying reality. We've seen it all before. And yet, somehow, this time... I don't really care.

Rot in hell Dexter Johnson, and may your journey there be painful to you. You caused all of this, and more.

Charlie Goes to Candy Mountain

H/T to my daughter.




Oh, and in case you were wondering......



Hehehe.

The Tag-A-Long

Occasionally, two people will arrive together to be evaluated in the ER. Unless the chief complaint is "S/P MVA" (status post motor vehicle accident) or "fever," then one of these patients will usually have some sort of acute medical problem and the other patient will be what I call the tag-a-long.

The tag-a-long patient would not usually seek medical attention at all for their minor ailment, much less in an Emergency Department. But their daughter was vomiting or their friend got cut with a beer bottle or their father was having chest pain, so they figure they might as well sign in to get checked out for that nagging tickle in their throat they have had for the last couple of weeks. Or their discharge. Or their diarrhea.

I like to know when two people arrive together with unrelated complaints, because if one of them signs in with a laceration, then I can usually afford to adjust the sensitivity of my life-threaten-o-meter for the other patient a little bit. Not that diarrhea is usually life-threatening anyway, but if you are a tag-a-long, you're more likely to get the medical screening exam sort of workup than the full-meal deal.

Because I hate tag-a-longs.

Sometimes it's hard to decide which is the "sick" patient and which is the tag-a-long, so I'll ask them. Let's see... you have a migraine, and your sister here has chest pain. Did your sister initially decide to seek care, and since you were going to be here for a while anyway, you decided your migraine was finally bad enough to require emergency treatment? Or was your sister just keeping you company while you were treated for your migraine, so while she was here she decided to get her chest pain checked out just for the heck of it too? What are the chances that you have an intracranial hemorrhage and your sister has a pulmonary embolism at the same time? That would be freaky, wouldn't it?

How to Move the Meat

He's not getting many comments on this series for some reason I can't understand. This is truly inspired excellence; a must-read for any practicing or training emergency physician. So I'll link it.

Besides, I'm too tired and lazy to post anything original right now. But I've got a couple of ideas in the works.

Things We Take For Granted

Breathing, for one.

Hang in there, SSG.

(Real) Nurses Rock

I'm only as good as the nurses I am working with.

Outstanding nurses make even the most difficult shifts run smoothly. It's amazing to watch, really. They not only can tell when their patients are "sick," initiate treatment before I am even aware of the patient, keep track of numerous medications and interventions, know the plan of care and the updated vital signs on their patients, write detailed and appropriate notes, identify many problems before I do, catch my mistakes, make appropriate suggestions, encourage appropriate dispositions, and accomplish all of the "little things" that make a patient's stay more comforting, safe, and efficient. Sometimes all they really need is my signature. I disagree with them at my peril.

I don't care if a nurse wears an "unapproved" T-shirt or holiday socks, if she chooses to display tattoos or piercings, or if he speaks a little too bluntly to the customers. I only care that the nurse is a good nurse. All of us in the trenches know who the good nurses are. Cut them some slack. Give them a raise. But don't chase them away for silly reasons like that. Looking like a good nurse or toeing the line like a good nurse doesn't make one a good nurse.

They can work anywhere, in any nursing situation. They don't have to find a niche. You can plug them into any ER, ICU, recovery room, or disaster scene and they will be outstanding nurses wherever they go. In fact, if you piss them off, they are likely to leave for greener pastures. They don't have to take any grief from busybody pencil-pushers. They can work anywhere. Their excellence ensures that they will prosper, as long as we maintain a relatively free market.

Because real nurses ROCK. You know who you are. And so do we.

The Dystonic Reaction

Some of my most memorable patients suffered from dystonic reactions. A dystonic reaction, for those unfamiliar with the term, is a reaction to certain medications, most notably antipsychotics, antiemetics, and antidepressants. The most common medications which I have seen cause these reactions are Phenergan, Compazine, Inapsine, and Haldol. Once you've seen (or had) this reaction, you will usually be able to recognize it.

It often starts with a vague feeling of uneasiness, which then progresses to anxiety, irritability, and the sensation that one wants to "get away" or crawl out of their skin. Soon after an injection of Compazine, if the patient suddenly demands to leave and is pacing the room or fidgeting with their sheets, you can bet they are having this reaction.

More severe reactions include muscle spasms (which range in severity from occasional twitching or jerking to bizarre posturing and uncontrolled flailing of extremities), tachycardia, and the inability to speak properly due to facial/tongue/neck spasms.

The first time I saw such a reaction was during residency training. A woman who was on Haldol seemed very agitated and was talking gibberish. I thought she was having an acute psychotic episode, so I administered some more Haldol. When that didn't work, I consulted my attending, who took one look at her and said "watch this." Immediately after he gave her a dose of IV benadryl, she relaxed and started talking normally. It was practically godlike.

Another time, a teenager was brought in sweating bullets with his tongue protruding from his mouth, unable to speak. He thought he had bought some Valium from a friend, but it turned out to be Haldol. Half an hour later, his buddy came in with the same symptoms. Interestingly, Valium can occasionally cause these reactions too.

One lady came directly from a Neurologist's office because she couldn't speak, appeared somewhat agitated, and seemed to be retarded. That's what he thought anyway. As it turned out, she had taken a Phenergan suppository that morning. After the magic Benadryl shot, she spoke as clearly as a teacher (which she happened to be), and she asked me to call the Neurologist to come see her in the ER so she could chew him out in person. Amazingly, he showed up to take the heat.

I have actually had to admit a couple of these patients. While dystonic reactions are not really life-threatening and are usually easily reversed (or at least greatly improved), I couldn't reverse these reactions no matter how much Benadryl, Cogentin, or Ativan I gave them, and they were thrashing about so much that they were unable to care for themselves and were at risk for injury. If the reaction is not easily reversible, alternative diagnoses should be considered.

It's obviously more fun to treat one of these reactions that comes in from the street than one you have caused yourself. Unfortunately, most of these reactions seem to occur after IV administration of medications in the hospital.

Grand Rounds 3,38

Nicely done by Dr. Val at Revolution Health.

I like the idea of presenters picking their own wildcard entries because I'm really too shy to submit my own. For future reference, any hosters are welcome to use any of my posts they please.

Little Boss

"Come on Spalding, open up for the doctor! Please?"

As soon as I walked into the room, I could tell who was running this show. His fierce blue eyes and icy stare revealed that this was a young man who was used to getting his way, even at the tender age of four. Well-coiffed and sporting a stylish private school polo shirt, he was destined to become a CEO someday, if he survived this episode of acute pharyngitis, that is.

In the battle of wills, he definitely had the advantage over his parents. Unswayed by their offers of toys or ice cream, he held his lips tightly closed, unwilling to play their little bargaining game. He already had enough toys to keep him occupied for a few years, I imagine. And he'd probably get ice cream any damned time he wanted it, regardless. Seconds, even.

He'd apparently never come up against the likes of a busy and slightly cranky ER doc though. Sorry little Napoleon, but a man's gotta do what a man's gotta do.

Someday you'll understand.

The Medical Screening Exam

"I cut my arm on something. I thought it might need stitches."

No, it doesn't need stitches. Just wash it with soap and water and put a BandAid on it.

"Are you sure? I don't want it to get infected or leave a scar."

Yes, I'm sure. It barely broke the skin. I can't make it heal any better than it's going to already.

"Well, it sure bled a lot."

It's not bleeding now. In fact, it's almost healed. When did it happen?

"Yesterday."

Oh. Well, just keep it clean and bandaged, and you'll be fine.

"Can you look at my toenail then?"

Sure...you've got a fungal infection of your toenail. Looks like it's been there for a while. You should see your doctor and he can prescribe some medication for it. That will take months to heal, so it's best treated by your regular physician.

"Is that all? You aren't going to do anything for me?"

I gave you proper medical advice. Sometimes that's all I can do. Good night.

"Can I get a work excuse?"

Lizard Neck

Perspective

Two sides to every story, by Hallway four. Outstanding.

This is an example of why patient complaint letters are mostly meaningless wastes of time.

via GruntDoc.

Escargot

What's more fun than finding a snail after a long day of playing in the pool?

Finding two snails, of course. Because then you can have snail races with your best friend. And what's more fun than that?

Note the wrinkly fingers.

The Malpractice Cast Net

Having been the intended victim of a few upset family members who have wrongly accused me of malpractice, I have a small bit of insight into the types of cases that are occasionally brought against physicians. In order to ease the pain of the natural but unexpected death of a loved one, and often to ease their own feelings of guilt, claims of malpractice are tossed out like a cast net by angry grieving relatives in the hope that a nice trout might be snared from amongst the bait. Of course before the net is pulled in, the circling sharks invariably take a huge chunk of the catch. There's usually enough left over to feed the family though. Admittedly, most of these attempts come up empty, never making it to trial or inducing a settlement offer, but they are still annoying. Even painful.

It all starts with a patient's unexpected death. Young healthy people aren't supposed to die, so obviously it must have been someone's fault. Did the patient seek the advice of a physician recently? Or maybe not so recently? The eager attorney will devour the bait without requiring the accusers to pay anything up front. It's her pleasure. The blood is in the water, and she is anticipating a big meal. Even if she doesn't get the big catch, she'll settle for some scraps to keep her fed. People die every day, and they usually seek medical attention at some point, so there is always plenty of bait. Heck, people sometimes go to the doctor just for a checkup. If a serious condition develops later, maybe it should have been picked up on the initial visit, right?

Is there any symptom or sign mentioned in the medical record that could be remotely connected to the cause of death? Never mind that certain symptoms are so vague and common that they aren't initially diagnostic of anything in particular, or that the initial signs of disease may be subtle. If the patient saw a physician even once, and the particular complaint (perhaps among many) wasn't fully addressed, then the fact that the patient died sometime thereafter is a red flag that negligence might have occurred. Chum for the sharks, you might say.

Perhaps more tests should have been done. Obviously the patient died, so the workup and treatment plan must have been inadequate, right? Negligent, even. Malpractice. Did the patient follow up again prior to his death? No? It must have been the physician's fault for not encouraging more aggressive followup. Maybe a certified letter should have been sent. Maybe the physician should have called the patient at home every day to inquire on the status of the condition, since the patient shouldn't be expected to take any responsibility for his own health.

The reaction to Flea's settlement among many in the blogosphere is disturbing. While none of us know the specific facts of the case nor the physician himself, I will say one thing: based on what I DO know, I would eagerly accept Dr. Flea as my own children's Pediatrician. Physicians like him are a rare breed these days. He takes his own call. He is available to his patients 24 hours a day. He makes house calls, for chrissakes. He obviously cares about his patients a great deal, and he seems to have superior medical knowledge and medical judgment. If anyone can't recognize these things, than they deserve the HMO assembly line care that is becoming all too common these days and that eventually all of us will likely have to settle for. The old-school docs are becoming extinct.

Why do I give him the benefit of the doubt? Because I too have been personally accused of negligence, and I have settled cases in which I gave appropriate care in order to eliminate the possibility of a megaverdict. Because I was a fan of his blog, and in his posts he shared his practice style with all of us. I am confident that he is not the sort of physician that would ignore his patient for five weeks if they needed him. Any of us can miss a diagnosis in the early stages of disease, and obviously many medical conditions become more apparent over time. So despite his mistakes regarding the trial blogging, I doubt he is responsible for the death of that patient.

I hope he will share the details of the case with us someday, but until I am convinced otherwise, I will stand behind him. If he decides to move to Texas, I've got a couple of patients already lined up for him, and I will gladly refer many more.